hospital and ambulatory surgery center payment manual 2006 · 2017. 1. 5. · on june 26, 2006 the...

Hospital and Ambulatory Surgery Center

Payment Manual

Effective October 1, 2006

South Carolina Workers’ Compensation Commission

South Carolina Workers’ Compensation Commission

Commissioner David W. Huffstetler, Chairman Commissioner Susan S. Barden, Vice Chair

Commissioner J. Alan Bass Commissioner George N. Funderburk

Commissioner G. Bryan Lyndon Commissioner Andrea P. Roche

Executive Director Gary R. Thibault

Division of Medical Services Julie K. Lewis, Director

Kandee W. Johnson, Medical Policy Analyst David F. Adcock, MD, MPH, Chief Medical Consultant

Telephone: 803.737.6201 803.737.5743

Email [email protected] Visit our website at www.wcc.sc.gov

mailto:[email protected]://www.wcc.sc.gov/

Hospital and Ambulatory Surgery Center Payment Manual

CONTENTS OVERVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 GENERAL POLICY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Effective Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Authorization to Treat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Medical Services Rendered in Another State . . . . . . . . . . . . . . . . 5 Out-of-State Injuries or Work-Related Illnesses Treated in South Carolina . . . . . . . . . . . . . . . . . . . . . . . . . 5 Submitting Claims for Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Collecting Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 "Balance Billing" and Collection Procedures . . . . . . . . . . . . . . . . 6 Copies of Records and Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Claims Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Timeliness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Explanation of Review (EOR) . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Disputed Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 INPATIENT AND OUTPATIENT PROSPECTIVE PAYMENT

SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

INPATIENT PROSPECTIVE PAYMENT SYSTEM . . . . . . . . . . . . . . . . 10

OUTPATIENT PROSPECTIVE PAYMENT SYSTEM . . . . . . . . . . . . . . 17

AMBULATORY SURGERY CENTERS . . . . . . . . . . . . . . . . . . . . . . . . . 22 WORKERS’ COMPENSATION MEDICAL LAWS AND REGULATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46


OVERVIEW The 2006 South Carolina Workers' Compensation Commission's Hospital and Ambulatory Surgery Center Payment Manual contains the policy governing the billing and payment of hospitals and ambulatory surgery centers for services rendered under the Workers’ Compensation Act. The payment rates listed herein are deemed by the Commission to be fair and reasonable and were developed under the statutory and regulatory authority provided by Title 42 of the Code of Laws of South Carolina, 1976, as amended, and Chapter 67, Article 13 of the Regulations of the Workers’ Compensation Commission. On June 26, 2006 the South Carolina Workers’ Compensation Commission approved revisions to its hospital inpatient and outpatient payment systems by adopting a prospective payment system for hospital inpatient, outpatient and ambulatory surgery center payments. Effective October 1, 2006, for all inpatient and outpatient services, including procedures performed in ambulatory surgery centers, the maximum allowable payment (MAP) will be calculated at 140% of the Medicare payment, that is, the Medicare payment rate plus 40%. The MAP represents the maximum amount that a provider can legally be paid for rendering services under the Workers’ Compensation Act. In instances where the provider’s usual charge is lower than the MAP amount, or where the provider has agreed by contract with an employer or insurance carrier to accept discounts or lower fees than the Commission’s MAP, payment is made at the lower amount. To facilitate the change to the new pricing systems, the Commission will price any hospital inpatient, outpatient or ambulatory surgery center bill at no charge to insurance carriers, self-insured funds or self-insured employers. Those bills may be sent to the Commission’s Medical Services Division and the bill will be re-priced according to Medicare’s current rate plus forty percent. When there is a dispute between any party concerning the payment for service, the provider or payer may request administrative review by the Commission’s Medical Services Division. The Commission will conduct the review according to its established process for reviewing disputed payments. (See page 8, Disputed Payments, and page 51, Regulation 67-1305, Medical Bill Review.) These changes are based in part on the recommendation of the Commission’s Hospital Advisory Committee. In a continuation of its efforts to assure that workers’ compensation medical fee schedules adequately pay for services provided, ensure access to quality care and contain costs for business and industry, the South Carolina Workers’ Compensation Commission reconvened the Hospital Advisory Committee in November 2004 to advise the Commission on what, if any, changes were necessary to improve the hospital inpatient payment system. The committee also was charged with making recommendations on the establishment of an outpatient fee schedule. The fourteen member Advisory Committee was composed of representatives of the hospital industry, medical association, property and casualty insurance carriers, a self-insured fund, business and industry, and state government.

1


The full committee met six times over an eighteen month period to review the current system, review analysis conducted by staff, and to develop recommendations for improving the hospital inpatient and outpatient payment systems. A subcommittee consisting of six members from the full committee was formed in the summer of 2005 to further analyze data, including information provided by one hospital and two insurance companies, and to compare the existing payment system with Medicare. Since 1997 the South Carolina Workers’ Compensation Commission’s hospital inpatient payment system has been based on Medicare’s diagnosis related groups (DRGs), a classification system which sorts inpatient claims into one of over 500 classifications. Each hospital discharge can be assigned to a DRG group based on the diagnoses, procedures performed, complications, co-morbidities, signs, and symptoms and discharge status. A DRG payment system is prospective in nature in that the price is set prior to services being rendered. Payment is based on the diagnosis related group the claim is assigned and determined by the resource needs for the average patient for that diagnosis group. Also included in this determination is length of stay and intensity of services. Patients within a given diagnosis related group will demonstrate similar resource consumption and length of stay patterns. These DRG classifications were developed by the Centers for Medicare and Medicaid Services (CMS) for the Medicare program. The use of DRGs continues with the payment system effective October 1, 2006. Prior to October 1, 2006, services performed on an outpatient basis at a hospital or ambulatory surgery center were not subject to the DRG classification payment methodology. In 1996 when the prior system was established by the Commission, Medicare was considering, but had not yet adopted, a prospective payment system for outpatient services. The 1997 amendments to the Commission’s regulations provided that the Commission would develop a prospective payment system for outpatient hospital services and ambulatory surgery centers. The regulations also provided that until a prospective payment system is operational, the payments for hospital outpatient services and ambulatory surgery centers shall be set by the Commission based on a discount-to-charge basis. While the former inpatient payment system was adequately designed for the financial and market conditions that existed in the early-to-mid 1990s, problems arose over the past five years. Even though DRG payment rates were held steady, costs continued to escalate as a result of charges increasing at such a significant rate that more and more claims fell into a category which received additional payment. Charges have increased at such a rate that both inpatient and outpatient billing no longer reflected actual cost of care. The gulf between costs and charges has widened and discounts to charges have increased with it - in part a result of rules or contracts established by different payment sources: Medicare, Medicaid, health insurance, workers’ compensation insurance, or other contracts entered into by providers and payers. Since 1996, inpatient and outpatient charges have increased 209% and 221% respectively. With inpatient discharges declining, the results over the past five years, on a per claim basis, have been worse. The average inpatient per claim charge has increased 27.5% annually since 2000. The average charge for outpatient claims has increased 16.3% over this same period of time.

2


The Commission expects the changes to establish prices that more closely reflect the cost of medical services, and to establish prices that are more competitive with those paid by large group health insurance companies – considering that workers’ compensation provides for a single source of payment with little or no bad debt for compensable claims. Hospital Inpatient Payment System The Medicare Inpatient Prospective Payment System (IPPS) was introduced by the federal government in October, 1983, to encourage more cost-efficient management of medical care and the Commission established a DRG payment system in 1997. A DRG payment system is prospective in nature in that the price is set prior to the services being rendered. Patients within a given diagnosis related group will demonstrate similar resource consumption and length of stay patterns. Each hospital discharge can be assigned a DRG based on the diagnoses, procedures performed, complications, co-morbidities (pre-existing conditions), signs and symptoms and discharge status. Also included in this determination is length of stay and intensity of services. Currently, there are 526 DRGs for which a hospital is paid a flat rate for the DRG except for cases that are unusually costly, called outliers. Costs incurred by the hospital for a case are evaluated to determine whether it is eligible for additional payments as an outlier case. These additional payments protect the hospital from large financial losses due to unusually costly cases. Specialty hospitals and units such as psychiatric and rehabilitation are excluded from the prospective payment system because the diagnosis related groups do not accurately account for the resource costs for the types of patients treated on an inpatient basis. Payments are based on a federal per diem base rate since there are wide variations in charges and lengths of stay. The facilities are paid on the basis of Medicare reasonable costs per case, limited by a hospital specific target amount per discharge. Outpatient Payment System In 1997, Medicare was considering adopting an Outpatient Prospective Payment System (OPPS) for outpatient services and the system was implemented in 2000. The 1997 amendments to the Commission’s regulations provided that the Commission would develop a prospective payment system for outpatient hospital services and services rendered by ambulatory surgery centers (Regulation 67-1304). Medicare’s Hospital Outpatient Payment System (HOPPS) reimburses outpatient services performed at a hospital by utilizing the Ambulatory Patient Classifications. APCs are similar to DRGs in that it is a prospective payment system which pays hospitals specific predetermined payment rates for outpatient services by using a classification system that groups claims which are similar in nature, have similar clinical characteristics and are similar in the kind and amount of resources that will be necessary, on average, to treat the case. APCs require that all outpatient bills use the Healthcare Common Procedure Coding System (HCPCS) including Current Procedural Terminology Codes (CPT). Each APC is assigned a relative payment weight based on the median cost of the services within the APC. Using an individual

3


hospital’s wage index, rates are adjusted across geographic areas for wage differences and the labor-related portion of the payment rate. A hospital may furnish a number of services to a beneficiary on the same day and receive an APC payment for each service; however, multiple surgical procedures performed on the same day are discounted. The Advisory Committee reviewed outpatient payment methods currently being used by other states for workers’ compensation programs. Ambulatory Surgery Centers (ASCs) operate exclusively for the purpose of furnishing outpatient surgical services to patients. An ASC is either independent (not a part of a provider of services or any other facility), or operated by a hospital (under common ownership, licensure or control of a hospital). Services performed on an outpatient basis at a hospital or an ambulatory surgery center is not subject to the DRG classification payment methodology. Under the Ambulatory Surgery Center (ASC) payment system, the payment rate is established on the basis of an estimate that takes into account the facility costs to perform a specific procedure. The overhead factor is calculated on a prospective basis which takes into account the volume for each listed procedure. Procedures on the approved ASC list currently are assigned to one of fifty-six payment groups. Medicare establishes a list of approved procedures that are commonly performed in an inpatient setting but can be safely performed in an outpatient setting.

4


GENERAL POLICY Effective Date The policies and payments listed in this manual are effective as of October 1, 2006. Any claim for services rendered on or after October 1, 2006 is subject to the payment methodologies described herein. For the purpose of determining payment, the date of service for an inpatient hospital stay is the date of admission. Authorization to Treat Health care providers must receive authorization from the employer or insurance carrier prior to providing treatment, except for emergency care when the carrier cannot be reached. When an employer authorizes treatment, whether verbally or in writing, the employer assumes liability for payment for that service, even if it is later determined the injury was not work-related. Whenever possible, providers should obtain written authorization from the employer. Providers may request the employer to fax a written authorization at the time authorization is given. If it is not possible to obtain written authorization, the provider should document the authorization by noting the date and time of the authorization and the name of the individual who authorized treatment. Verifying that the employer has workers' compensation insurance coverage is not authorization to treat. Medical Services Rendered in Another State The payment rates listed in this manual are not applicable to medical services rendered outside the state of South Carolina even when the services are provided under the South Carolina Workers' Compensation Act. Insurers and self-insurers should negotiate rates with out-of-state providers prior to authorizing care. Out-of-State Injuries or Work-Related Illnesses Treated in South Carolina It is possible that an individual may receive medical services in South Carolina for injuries incurred in an accident under the jurisdiction of another state's workers' compensation act. In this case, the policy and procedures listed herein would not apply. However, when a worker receives medical services in South Carolina pursuant to the South Carolina Act, the payment is subject to the policy listed in this document regardless of where the injury occurred. Providers may contact the payer to determine whether benefits are being provided pursuant to South Carolina law or the laws of another state.

5


Submitting Claims for Payment Insurance companies, self-insurance funds, or self-insured employers providing workers' compensation coverage are directly responsible for issuing payments to authorized providers. Providers should submit claims to the employer or insurance carrier for payment. (The Commission does not pay health care providers.) A provider who is unsure who the insurance carrier is may contact either the employer, the Commission's Coverage Division (803.737.5704), or verify the employer’s insurance company’s name and address via the Commission’s web site at www.wcc.sc.gov/Insurance/Verify+Coverage/. Collecting Payment To determine the status of an unpaid claim, please contact the employer or insurance carrier. "Balance Billing" and Collection Procedures Against the Claimant Medical providers are to be paid for authorized services at rates no higher than those specified in this document. If a provider's charge is greater than the amount approved by the Commission, the provider must not bill the patient or the employer for the difference. It is unlawful for a medical provider to actively pursue collection procedures against a workers’ compensation claimant prior to the final adjudication of the claimant’s claim. A medical provider who violates this regulation after receiving written notice from the claimant or the claimant’s attorney is guilty of a misdemeanor and may be fined up to $500, payable to the claimant. (See page 48, §42-9-360.) Copies of Records and Reports Providers must submit copies of records and reports to insurance carriers, claimants or their attorney, or the Commission, upon request. Providers may not charge for supplying documents when such documents are requested by the Commission or when supplying an initial copy to the reviewer/payer for the purpose of substantiating charges and/or medical necessity. (See page 51, §42-15-95, and page 53, Regulations 67-1301 and 67-1303). In those instances where a charge is allowed, the maximum charge for providing records and reports is $15 clerical fee plus 65¢ per page for the first thirty pages, and 50¢ per page for each page over thirty, plus sales tax and actual cost for postage to mail the documents. Providers who use a medical records company to make and provide copies of medical records must ensure that neither the Commission nor the reviewer is billed for the cost of copies when the purpose of the copies is to substantiate charges and/or medical necessity.

6


Providers do not need authorization from the injured worker to release to the employee, employer, insurance carrier, their attorneys, or to the Commission, medical records relating to a workers’ compensation injury or illness. (See page 49, §42-15-95.) Claims Review All claims for payment of medical services rendered under the Workers' Compensation Act must be reviewed prior to payment to ensure that the services rendered were reported accurately on the claim form and that payment is made according to the policies and payments outlined in this document. The Commission requires insurance carriers, self-insured employers and third party administrators to become approved by the Commission to conduct claims review. Parties interested in becoming approved reviewers should contact the Medical Services Division. A provider who has a question regarding a payment or reduction should write or call the party that reviewed the claim prior to contacting the Commission. If the matter cannot be resolved by contacting the reviewer, submit the claim and any documentation to the South Carolina Workers' Compensation Commission Medical Services Division for review. (See page 8, Disputed Payments.) Timeliness Payment to authorized medical providers are to be made within thirty (30) days of the request for payment, pursuant to §42-9-360. Exceptions to the thirty day requirement may be made when the bill has been submitted to the Commission for review, or when documentation necessary to the bill review was not submitted with the claim and must be requested from the provider. In cases where documentation must be requested from the provider, payment must be made within 30 days of receipt of the requested information. Explanation of Review (EOR) The Commission and entities approved by the Commission may review and reduce provider charges to coincide with the guidelines and payment rates described in this document. When issuing payment to a provider, the reviewer/payer must include an Explanation of Review (EOR). The EOR must explain why the charge(s) has been reduced or disallowed. If the reviewer/payer uses codes to explain the adjustment, it must furnish the provider with a written explanation of each code used. The EOR must also include appropriate identifying information so the provider can relate a specific payment to the applicable claimant, the procedure billed and the date of service. All EORs must include a notice informing providers of their right to request an administrative review by the Commission's Medical Services Division in case of a disputed payment that cannot

7


be resolved by contacting the reviewer/payer. Disputed Payments When a provider disagrees with a review and payment for any service, the provider may make a written request for reconsideration to the reviewer/payer within 60 days from receipt of the EOR. The request must include a copy of the claim in question, the EOR and any supporting documentation to substantiate the charge/service in question. A dispute must be based on extenuating circumstances involved in the case or the provider’s belief that the review was not in accordance with Commission policy. Upon receipt of a request for reconsideration, the reviewer/payer must review and re-evaluate the original bill and accompanying documentation, using a medical consultant if necessary, and respond to the provider within 30 days of the date of receipt. The payer's response to the provider must explain the reason(s) behind the decision and cite the specific policy upon which the final adjustment was made. If the provider finds the result of the reviewer/payer's reconsideration unsatisfactory, that provider may then request an administrative review by the Commission’s Medical Services Division. Providers may send a written request for resolution of a disputed payment to the Division within 60 days of the payer's reconsideration, or 90 days from the date of the original request for reconsideration when the payer has not responded. A request for resolution of a disputed payment must include the following: 1) Copies of the original and resubmitted bills; 2) Copies of the Explanation of Payment; 3) Copies of any supporting documentation to include

physician’s medical notes and/or operative reports. 4) Copies of correspondence and/or specific

information regarding contact with the payer. The Medical Services Division will review the information, make a determination and provide written notification of its decision to both the provider and the payer within 30 days of receipt. Send requests to resolve a dispute to: Medical Services Division South Carolina Workers' Compensation Commission Post Office Box 1715 Columbia, SC 29202-1715

8


INPATIENT AND OUTPATIENT PROSPECTIVE PAYMENT SYSTEMS

A prospective payment system (PPS) is a method of reimbursement in which payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service. (For example, DRGs for inpatient hospital services) CMS uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing. The South Carolina Workers’ Compensation Commission’s DRG and APC Grouping software program will be updated quarterly as Medicare updates payment policies and prices. The ASC payment groups will be updated as needed to reflect any additions or deletions. The Medical Services Division will assist insurance carriers, self-insured funds, and self-insured employers in pricing hospital inpatient and outpatient and ambulatory surgery center claims free of charge. Claims submissions must be directly mailed to the Medical Services Division to ensure legibility. Claims and supporting documentation to include hospital and/or physician’s notes and operative notes may be mailed to the address listed below. Medical Services Division South Carolina Workers’ Compensation Commission

1612 Marion Street Post Office Box 1715 Columbia, SC 29202-1715

9


INPATIENT PROSPECTIVE PAYMENT SYSTEM (IPPS) The IPPS is a system of payment for acute hospital inpatient stays under Medicare Part A based on prospectively set rates. The specific payment amount is based on the diagnosis related group (DRG) assigned to the claim based on clinical information. The payment amount for each DRG is intended to cover the necessary costs of the average patient assigned to that DRG. The amounts paid to hospitals are adjusted depending on whether the hospital is in a large urban area or in another area, whether it is a teaching hospital, and whether it serves a disproportionate share of indigent patients. The payment amount also is adjusted to account for the different labor costs and market conditions in different areas. Hospitals also may receive an additional payment called an “outlier payment” for exceptionally costly cases. The base payment rate is comprised of a standardized amount, which is divided into labor-related and non-labor share. The labor-related share is adjusted by the wage index applicable to the area where the hospital is located. The DRG payment is the base amount multiplied by the DRG “relative weight”. Relative Weight Each DRG is assigned a “relative weight”, which reflects the average relative costs of cases in the DRG compared to that for the average Medicare case. These weights are adjusted each year and are used to set payment rates. Wage Index As part of the methodology for determining prospective payments to hospitals, standardized amounts are adjusted "for area differences in hospital wage levels by a factor reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level." This adjustment factor is the wage index. The wage index adjustment factor is applied only to the labor portion of the standardized amounts and is updated annually. Disproportionate Share Hospital (DSH) A DSH can receive an additional percentage add-on payment if the hospital is recognized as serving a disproportionate share of low-income patients.

10


Indirect Cost of Medical Education (IME) Prospective payment hospitals that have residents in an approved graduate medical education (GME) program receive an additional payment to reflect the higher patient care costs of teaching hospitals relative to non-teaching hospitals. This additional payment is known as the IME adjustment. Outlier Payment An additional payment is provided in addition to the DRG adjusted base payment rate for cases incurring extraordinarily high costs. These payments are called outlier payments. The costs incurred by the hospital for the case are evaluated to determine whether it is eligible for additional payments as an outlier case. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases. To qualify for outlier payments, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments in order to qualify for outliers). Hospital-specific cost-to-charge ratios are applied to the covered charges for a case to determine whether the costs of the case exceed the fixed-loss outlier threshold. Payments for eligible cases are then made based on a marginal cost factor, which is a percentage of the costs above the threshold. CMS publishes the outlier threshold in the annual Inpatient Prospective Payment System (IPPS) Final Rule. The actual determination of whether a case qualifies for outlier payments takes into account operating and capital costs and DRG payments. Thus, the combined operating and capital costs of a case must exceed the fixed loss outlier threshold to qualify for an outlier payment. The operating and capital costs are computed separately by multiplying the total covered charges by the operating and capital cost-to-charge ratios. The estimated operating and capital costs are compared with the fixed-loss threshold after dividing that threshold into an operating portion and a capital portion (by first summing the operating and capital ratios and then determining the proportion of that total comprised by the operating and capital ratios and applying these percentages to the fixed-loss threshold). The thresholds are also adjusted by the area wage index (and capital geographic adjustment factor) before being compared to the operating and capital costs of the case. Finally, the outlier payment is based on a marginal cost factor equal to 80 percent of the combined operating and capital costs in excess of the fixed-loss threshold (90 percent for burn DRGs). Cost-to-charge ratios Hospital-specific cost-to-charge ratios are applied to the covered charges for a case to determine whether the costs of the case exceed the fixed-loss outlier threshold. CMS publishes a detailed list of cost-to-charge ratios by provider and by Federal Fiscal Year in the Impact File.

11


Assigning a DRG Classification The DRG classifications are those developed by CMS for the Medicare program. All claims for inpatient hospital services must be assigned a DRG classification based in general on the diagnoses, procedures performed, complications, co-morbidities, signs, symptoms, length of stay and discharge status. Determining Payment Elements of the IPPS Payment

• The standardized amounts, which are the basic payment amounts. • A wage index to account for differences in hospital labor costs. • The DRG relative weights, which account for differences in the mix of patients treated

across hospitals. • An add-on payment for hospitals that serve a disproportionate share of low-income

patients (DSH). • An add-on payment for hospitals that incur indirect cost of medical education (IME). • Outlier payment, determine if the case qualifies for additional payment.

Hospital Specific DRG Payment = PPS Operating Payment + PPS Capital Payment Calculations: PPS Operating Payment:

DRG Relative Weight x [(Standardized Labor Share x Operating Wage Index) + (Standardized Non-Labor Share)] x (1 + Operating IME + Operating DSH Adjustment Factor)

PPS Capital Payment: DRG Relative Weight x (Standard Federal Rate) x (GAF) x (Large Urban Add-on, if applicable) x (1 + DSH Adjustment Factor + IME Adjustment Factor)

Location of elements for PPS Operating Payment (The FY files should reflect the date of service) Date Element Location Standardized Labor Share Federal Register Final Rule Operating Wage Index PPS Impact File Standardized Non-Labor Share Federal Register Final Rule Operating IME Adjustment PPS Impact File Operating DSH Adjustment Factor PPS Impact File DRG Weight DRG Relative Weight File

12


Location of elements for PPS Capital Payment (The FY files should reflect the date of service) Date Element Location Capital Standard Federal Payment Rate Federal Register Final Rule Geographic Cost (GAF) Federal Register Final Rule Large Urban Add-On (if applicable) 1.03 (fixed adjustment factor since 1993) Capital IME Adjustment PPS Impact File Capital DSH Adjustment Factor PPS Impact File DRG Weight DRG Relative Weight File When calculating an IPPS payment, the FY file should be used to reflect the date of service. All data elements are updated annually in the Federal Register Final Rule.

1. Identify the CMS Medicare provider number for the hospital. If you do not have the provider number, you can search by facility name or state on the American Hospital Directory website www.ahd.com.

2. Download the following two files from the CMS website

www.cms.hhs.gov/AcuteInpatientPPS/. • Inpatient PPS Final Rule Impact File for corresponding year. The PPS Impact file

supplies hospital specific information such as the wage indices, DSH, and IME. • DRG Relative Weights File

3. Search the Federal Register Final Rule for the following tables:

• National Adjusted Operating Standardized Amounts, Labor/Non-labor • Capital Standard Federal Payment Rate • Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas • Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas • Wage Index and Capital Geographic Factor (GAF) for hospitals that are

reclassified (this table is used when the hospital is identified as reclassified; see variable “reclassification status” in PPS Impact File)

4. Calculate the PPS Hospital Specific DRG Price. The calculation is broken down into two separate calculations:

1) PPS Operating Payment, and 2) PPS Capital Payment.

PPS Operating Payment DRG Relative Weight x [(Standardized Labor Share x Operating Wage Index) + (Standardized Non-Labor Share)] x (1 + Operating IME + Operating DSH Adjustment Factor)

13

http://www.ahd.com/http://www.cms.hhs.gov/AcuteInpatientPPS/


PPS Capital Payment DRG Relative Weight x (Standard Federal Rate) x (GAF) x (Large Urban Add-on, if applicable) x (1 + DSH Adjustment Factor + IME Adjustment Factor) PPS Operating Payment + PPS Capital Payment = Hospital Specific DRG Payment Outlier Payment

1. Determine Costs: Operating Costs = Billed Charges x Operating Cost-to-Charge Ratio Capital Costs = Billed charges x Capital Cost to-Charge-Ratio 2. Determine Outlier Threshold

Fixed Loss Threshold (Published in the Federal Register Final Rule for each year) Determine Operating Cost-to-Charge Ratio to Total Cost-to-Charge Ratio (hospital specific) = (Operating CCR) / (Operating CCR + Capital CCR) Calculate Operating Outlier Threshold = {[Fixed Loss Threshold x ((Labor related portion x CBSA wage index) + Non-labor related portion)] x Operating CCR to Total CCR} + PPS Operating Payment Determine Capital Cost-to-Charge Ratio to Total Cost-to-Charge Ratio (hospital specific) = [Capital CCR) / (Operating CCR + Capital CCR)] Calculate Capital Outlier Threshold = (Fixed Loss Threshold x Geographic Adjustment Factor x (Large Urban Add-On, if applicable) x Capital CCR to Total CCR) + PPS Capital Payment Determine Outlier Payment: Marginal Cost Factor 0.80 of the combined operating and capital costs in excess of the fixed-loss threshold Outlier Payment = (Cost – Outlier Threshold) x Marginal Cost Factor Calculate Outlier Payment for both operating and capital. Combined operating and capital costs for a case must exceed the combined threshold to qualify for an outlier payment. The following information for the FY is found on the CMS website under Acute Inpatient PPS: DRG Relative Weights: Acute Inpatient File for Download www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp Wage Index Tables: Acute Inpatient Wage Index Files www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp DSH Adjustment Factor: DSH Adjustment Factor, IME Adjustment Factor, Operating Cost-to-Charge Ratio, and Capital Cost-to-Charge Ratio: Acute Inpatient Files for Download

14

http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asphttp://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp


www.cms.hhs.gov/AcuteInpatientPPS/FFD/itemdetail.asp

Standardized Labor/Non-Labor Share, Standard Federal Payment Weight, and Geographic Cost Factor tables can be downloaded from CMS or the Federal Register at the GPOAccess website. http://www.cms.hhs.gov/AcuteInpatientPPS/IPPS/list.asp www.gpoaccess.gov/fr/index Inpatient Psychiatric Facility Inpatient Psychiatric facilities are excluded from the Inpatient Prospective Payment System (IPPS) and are not paid the DRG amount provided under the DRG Payment system used in the IPPS. Rather, they are paid under the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) using a base rate with the possibility of various adjustments. Each DRG has a calculated adjustment factor specific to the diagnoses of which it is comprised. The IPF PPS uses the existing inpatient hospital DRG system to group inpatient psychiatric patients into one of the 15 allowed psychiatric DRG groups but does not use the inpatient PPS payment amount. The IPF PPS has its own set of payment adjustment factors for each of the DRG codes allowed. The DRG payment adjustment amounts are applied to the Federal per diem rate along with any other applicable payment adjustments to compute the final per diem amount for each inpatient psychiatric stay. A Federal per diem base rate is set for each fiscal year which is broken into labor-share and non-labor-share. The Federal per diem base rate provides patient-level and facility-level adjustments. Additional payments are provided for cost outlier cases. The Inpatient Psychiatric Facility PPS PC PRICER makes all reimbursement calculations applicable under the IPF PPS including all payment adjustments. The IPF PPS PC Pricer can be downloaded from the CMS website at www.cms.hhs.gov/PCPricer/. Inpatient Rehabilitation Facility Inpatient Rehabilitation facilities (IRFs) include free standing rehabilitation hospitals and rehabilitation units in acute care hospitals. They provide an intensive rehabilitation program. IRFs are also exempt from the Inpatient Prospective Payment System (IPPS) and are paid under the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). The IRF PPS utilizes information from a patient assessment instrument (IRF PAI) to classify patients into distinct groups based on clinical characteristics and expected resource needs. Separate payments are calculated for each group, including the application of case and facility level adjustments. The IRF PPS PC Pricer can be downloaded from the CMS website www.cms.hhs.gov/PCPricer/.

15

http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/itemdetail.asphttp://www.cms.hhs.gov/AcuteInpatientPPS/IPPS/list.asphttp://www.gpoaccess.gov/fr/indexhttp://www.cms.hhs.gov/PCPricer/http://www.cms.hhs.gov/PCPricer/


Payment The Maximum Allowable Payment (MAP) will be calculated at 140% of the Medicare payment. The MAP represents the maximum amount that a provider can legally be paid for rendering services under the Workers’ Compensation Act. In instances where the provider’s usual charge is lower than the MAP amount, or where the provider has agreed by contract with an employer or insurance carrier to accept discounts or lower fees than the Commission’s MAP, payment is made at the lower amount.

16


OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) Ambulatory Payment Classifications (APCs) Hospitals are paid specific predetermined payment rates for services that are calculated based on grouping outpatient services into ambulatory payment classifications (APCs). Services within an APC are similar clinically and require comparable resources. Each APC is assigned a relative payment rate based on the median cost of the services within that classification. The payment rates are initially determined on a national basis; however, the rates actually paid to hospitals in an area will vary, depending on the area’s wage level. To adjust for wage differences across geographic areas, the labor-related portion of the payment rate (60 percent) is wage adjusted, using the individual hospital’s wage index. (See CMS web site http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp.) Some incidental items and services will be packaged into the APC payment. No separate payment is made for packaged services because the cost of these items is included in the APC payment for the service of which they are a primary part. Supplies, anesthesia, recovery room and certain drugs are considered to be a primary part of a surgical procedure and payment for these items is packaged into the APC payment. (See Payment Policies) Implantable orthotic and prosthetic devices and implantable DME are paid under the OPPS when billed with the appropriate HCPCS and revenue codes. Payment for non-implantable orthotic and prosthetic devices furnished by an OPPS hospital is made under Medicare’s Durable Medical Equipment, Prosthetic Orthotic, and Supply (DMEPOS) fee schedule when billed with the appropriate HCPCS and revenue code. Non-implantable DME furnished by an OPPS hospital should be billed on the CMS-1500 Form. Payment will be made under the DMEPOS fee schedule. Depending on the services provided, a hospital may be paid for more than one APC for an encounter; however, multiple surgical procedures performed on the same day will be discounted. Full payment may be made for the highest paid procedure and 50 percent will be paid for each additional surgical procedure. APC groups, relative payment rates, wage adjustments, outlier payments are reviewed by CMS on an annual basis. The annual updates are made final through the publication of proposed and final rules in the Federal Register. (See http://www.cms.hhs.gov/providers/hopps/) The Outpatient Code Editor (OCE) will be used to determine permissible consolidation in order to identify mutually exclusive procedures and comprehensive and component procedure code combinations that are reimbursable for the same operative session when rendered by the same provider on the same date of service.

17

http://www.cms.hhs.gov/providers/hopps/


Billing Procedures Hospital outpatient services are billed on Form CMS-1450 (UB-92). HCPCS Codes HCPCS codes are entered in field # 44 and are required for all outpatient hospital services unless specifically excepted in CMS’s manual instructions. Codes are required for surgery, radiology, other diagnostic procedures, clinical diagnostic laboratory, durable medical equipment, orthotic-prosthetic devices, take-home surgical dressings, therapies, preventative services, blood and blood products and most drugs. Revenue Codes Hospitals are to report the HCPCS codes under the revenue center where they were performed. Revenue Codes are entered in field 42. The following revenue codes when billed without HCPCS codes are packaged services for which no separate payment is made; however, the cost of these services is included in the transitional outpatient payment and outlier calculations. 0250, 0251, 0252, 0254, 0255, 0257, 0258, 0259, 0260, 0262, 0263, 0264, 0269, 0270, 0271, 0272, 0275, 0276, 0278,0279, 0280, 0289, 0370, 0371, 0372, 0379, 0390, 0399, 0560, 0569, 0621, 0622, 0624, 0630, 0631, 0632, 0633, 0637, 0681, 0682, 0683, 0684, 0689, 0700, 0709, 0710, 0710, 0719, 0720, 0721, 0762, 0810, 0819, and 0942. Modifiers Modifiers are a 2-digit code that are reported next to the CPT code to indicate a service or procedure has been performed or altered by a specific set of circumstances that do not change the definition of the code. There is a space for two modifiers, one in field 6 and one in field 7. When it is appropriate to use a modifier, the most specific modifier should be used first. Line Item Date of Services A line item date of service must be entered in field 45 for each HCPCS code reported. Description of Service Provided A description of the service provided should be entered in field 43.

18


Reporting Service Units Service units must be reported to determine the number of times the service or procedure being reported was performed. Service units are entered in field 46. Charges Total charges for each service reported are entered in field 47. Payment The Maximum Allowable Payment (MAP) for services under the OPPS will be calculated at 140% of the Medicare payment. The MAP represents the maximum amount that a provider can legally be paid for rendering services under the Workers’ Compensation Act. In instances where the provider’s usual charge is lower than the MAP amount, or where the provider has agreed by contract with an employer or insurance carrier to accept discounts or lower fees than the Commission’s MAP, payment is made at the lower amount. National Correct Hospital Outpatient PPS NCCI Coding Initiatives Edits The CCI edits are part of the Outpatient Code Editor that determines payment for OPPS Services. Column 1/Column 2 Correct Coding Edits (formerly Comprehensive/Component) apply to code combinations where one of the codes is a component of a more comprehensive code. Payment is allowed only for the comprehensive code. Mutually exclusive codes are those codes that cannot reasonably be done in the same session. CPT codes that are mutually exclusive of one another based either on the CPT definition or the medical impossibility/improbability that the procedures could be performed at the same session can be identified as code pairs. Code pairs should not be reported together. New HCPCS codes have been introduced to describe hospital emergency visits provided in part-time dedicated emergency departments that are not open 24 hours per day, seven days per week. The G-codes will be paid as hospital clinic visits. Critical care services now include the activation of a trauma response team. In addition to reporting CPT codes 99291 and 99292, providers must report G0390.

19


Payment Status Indicators CMS has identified payment status indicators that determine if a service is paid under the OPPS or a different fee schedule, or if the service is not paid due to packaging rules. Status Indicator A: Services furnished that are paid under a fee schedule or payment system other than OPPS include:

• Ambulance services • Clinical Diagnostic Laboratory Services • Non-Implantable Prosthetic and Orthotic Devices • Physical, Occupational, and Speech Therapy • Routine Dialysis Services Provided in a Certified Dialysis Unit of a Hospital • Diagnostic and Screening Mammography

Status Indicator B: May be paid when submitted on a different bill type but are not paid under OPPS. These codes are not recognized by OPPS. An alternative code may be available. Status Indicator C: Inpatient Procedures not paid under OPPS Status Indicator D: Discontinued Codes not paid under OPPS Status Indicator E: Items, Codes, and Services that are not covered but for which an alternate code for the same item or service may be available. Status Indicator F: Corneal Tissue Acquisition and certain CRNA Services and Hepatitis B Vaccines: Not paid under OPPS. Status Indicator G: Pass Through Drugs and Biologicals: Paid under OPPS; Separate APC Payment includes pass-through amount. Status Indicator H: Pass-Through Categories: Separate cost-based pass-through payment. Status Indicator K: Non-Pass-Through Drugs, Biologicals, and Radiopharmaceutical Agents, Brachytherapy Sources, and Blood and Blood Products: Paid under OPPS; Separate APC Payment. Status Indicator L: Influenza Vaccine, Pneumococcal Pneumonia Vaccine: Not paid under OPPS. Status Indicator M: Items and Services Not Billable; Not paid under OPPS. Status Indicator N: Items and Services Packaged into APC Rates: Paid under OPPS; Payment is packaged into payment for other services, including outliers. There is no separate APC payment.

20


Status Indicator P: Partial Hospitalization: Paid under OPPS; Per diem APC payment. Status Indicator Q: Packaged Services Subject to Separate Payment Under OPPS Payment Criteria: Paid under OPPS. Separate APC payment based on OPPS payment criteria. If criteria are not met, payment is packaged into payment for other services, including outliers. There is no separate APC payment. Status Indicator S: Significant Procedure, Not Discounted when Multiple: Paid under OPPS; Separate APC Payment. Status Indicator T: Significant Procedure, Multiple Reduction Applies: Paid under OPPS; Separate APC payment. Status Indicator V: Clinic or Emergency Department Visit: Paid under OPPS; Separate APC payment. Status Indicator Y: Non-Implantable Durable Medical Equipment: Not paid under OPPS; All institutional providers other than home health agencies bill to DMERC. Status Indicator X: Ancillary Services: Paid under OPPS; Separate APC payment. Outlier Payments Outlier payments are automatically calculated based on each individual OPPS line item service and are intended to partially compensate hospitals for certain high cost services. To be eligible for an outlier payment, the estimated costs for a service must be greater than 1.75 times the payment amount for the APC and greater than the APC payment amount and the outlier threshold. The outlier threshold for 2007 is $1,825.00. The outlier payment is 50% of estimated cost less 1.75 times the APC payment amount. Process and information required to apply for assignment and payment for new technology APCs can be accessed at http://cms.hhs.gov/regulations/hopps/finalnewtechapc11602,pdf. Process and information required to apply for transitional pass-through payment for additional device categories can be accessed at http://cms.hhs.gov/regulations/hopps/newcatapp11602final1.pdf. CMS updates the OPPS on a quarterly basis to account for changes such as adding new pass-through drugs and/or devices, adding new treatments and procedures to the new technology APCs, removing procedures from the inpatient list, and recognizing new HCPCS codes that may be added during the year. These updates can be accessed at http://www.cms.gov/manuals/cmsindex.asp.

21

http://cms.hhs.gov/regulations/hopps/finalnewtechapc11602,pdfhttp://cms.hhs.gov/regulations/hopps/newcatapp11602final1.pdfhttp://www.cms.gov/manuals/cmsindex.asp


AMBULATORY SURGERY CENTERS Ambulatory Surgery Centers (ASCs) furnish outpatient surgical services for procedures that are on Medicare’s list of ASC approved procedures. The ASC payment rate is a standard overhead amount established on the basis of an estimate of a fee that takes into account the costs incurred by ASC’s in providing facility services in connection with performing a specific procedure. The overhead factor takes into account the volume for each listed procedure. The Centers for Medicare & Medicaid Services (CMS) publishes a list of procedures for which an ASC may be paid each year, including periodic updates of ASC HCPCS additions, deletions, and master listing files. This includes applicable codes, payment groups, and payment amounts for each ASC group. The ASC payment rate includes only the specific ASC services. Some medical services which are not on the list, such as physician services, anesthetist services, prosthetic devices, and DME may be covered and separately billable by the rendering provider for which payment may be made under other provisions. Approved Procedures To access the complete list of ASC approved HCPCS codes and payment rates, please visit the CMS website at www.cms.hhs.gov/ASCPayment. These files contain the procedure codes which may be performed in an ASC under the Medicare program as well as the ASC payment group assigned to each of the procedure codes. The ASC payment group determines the amount that is paid for facility services furnished in connection with a covered procedure. An ASC may not bill for procedures that require more than an ASC level of care or minor procedures that are normally performed in a physician’s office. Only those procedures which are on Medicare’s approved ASC HCPCS list will be reimbursed. ASC Facility Services The ASC payment rate includes all facility services furnished by the ASC in connection with a covered procedure and may not be billed separately. Examples of ASC facility services include:

• Nursing services, services of technical personnel, and other related services; • The use by the patient of the ASC facilities; • Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment; • Diagnostic or therapeutic items and services; • Administrative, recordkeeping, and housekeeping items and services; • Blood, blood plasma, platelets, etc., except for those to which the blood deductible

22

http://www.cms.hhs.gov/ASCPayment


applies; • Materials for anesthesia; and • Intraocular lenses (IOLs) except for new technology IOLs (NTIOLs) (refer to 42 CFR 416.180-200 ).

Services Furnished in ASCs Which Are Not ASC Facility Services Some medical services and a number of items may be furnished in an ASC which are not considered facility services and which the ASC payment does not include. The non-ASC services are covered and paid for under the applicable SCWCC fee schedule. Examples of non-ASC facility services include:

• Physician services; • The purchase or rental of non-implantable durable medical equipment (DME) to ASC patients for use in their homes; • Non-implantable prosthetic devices; • Implantable prosthetic devices except intraocular lenses (IOLs and NTIOLs), and accessories; • Leg, arm, back and neck braces; • Artificial legs, arms and eyes; and • Services furnished by a certified laboratory.

Multiple Procedures More than one surgical procedure may be performed in the same operative session. Special rules apply to this situation. When two or more procedures are performed, the ASC will be reimbursed at the full rate for the procedure classified in the highest payment group. Any other procedures performed during the same session are reimbursed at 50% of the procedure’s applicable group rate. If more than one procedure in the same payment group is performed, one procedure will be paid at the full payment rate and the remaining procedure(s) at 50 % of the payment rate. Correct Coding The Correct Coding Initiative (CCI) will be utilized in order to determine the appropriate billing of CPT and HCPCS codes. In general, if an ASC bills a CPT/HCPCS code that is considered to be a component part of a more comprehensive service for the same patient on the same date of service, only the more comprehensive code is covered, provided that code in on the list of ASC approved codes.

23


Billing Procedures HCPCS/CPT Codes are billed on the HCFA Form 1500 and are assigned to one of the fifty-six payment groups. Payment The Maximum Allowable Payment (MAP) will be calculated at 140% of the Medicare payment. (See pages 24-45 for the 2007 MAPs for each HCPCS/CPT code. The MAP represents the maximum amount that a provider can legally be paid for rendering services under the Workers’ Compensation Act. In instances where the provider’s usual charge is lower than the MAP amount, or where the provider has agreed by contract with an employer or insurance carrier to accept discounts or lower fees than the Commission’s MAP, payment is made at the lower amount. Internet Resources South Carolina Workers’ Compensation Commission www.wcc.sc.gov Medicare www.cms.hhs.gov/home/medicare.asp www.cms.hhs.gov/center/asc.asp www.palmettogba.com

24

http://www.wcc.sc.gov/http://www.cms.hhs.gov/home/medicare.asphttp://www.cms.hhs.gov/center/asc.asphttp://www.palmettogba.com/


25

2007 ASC HCPCS Codes, Groups and Payment Rates

HCPCS CODE

HCPCS CODE

HCPCS CODE

ASC Payment

Group

ASC Payment

Group

ASC Payment

Group

SCWCC Maximum Allowable Payment



0176T 09 $1,874.60 0177T 09 $1,874.60 10121 02 $624.40 10180 02 $624.40 11010 37 $352.13 11011 37 $352.13 11012 37 $352.13 11042 28 $230.19 11043 28 $230.19 11044 52 $592.34 11404 01 $466.20 11406 02 $624.40 11424 02 $624.40 11426 02 $624.40 11444 01 $466.20 11446 02 $624.40 11450 02 $624.40 11451 02 $624.40 11462 02 $624.40 11463 02 $624.40 11470 02 $624.40 11471 02 $624.40 11604 51 $585.89 11606 02 $624.40 11624 02 $624.40 11626 02 $624.40 11644 02 $624.40 11646 02 $624.40 11770 03 $714.00 11771 03 $714.00 11772 03 $714.00 11960 02 $624.40 11970 03 $714.00 11971 01 $466.20 12005 17 $127.74 12006 17 $127.74 12007 17 $127.74 12016 17 $127.74 12017 17 $127.74 12018 17 $127.74

12020 17 $127.7412021 17 $127.7412034 17 $127.7412035 17 $127.7412036 17 $127.7412037 42 $452.5912044 17 $127.7412045 17 $127.7412046 17 $127.7412047 42 $452.5912054 17 $127.7412055 17 $127.7412056 17 $127.7412057 42 $452.5913100 42 $452.5913101 42 $452.5913102 17 $127.7413120 17 $127.7413121 17 $127.7413122 17 $127.7413131 17 $127.7413132 17 $127.7413133 17 $127.7413150 42 $452.5913151 42 $452.5913152 42 $452.5913153 17 $127.7413160 02 $624.4014000 02 $624.4014001 03 $714.0014020 03 $714.0014021 03 $714.0014040 02 $624.4014041 03 $714.0014060 03 $714.0014061 03 $714.0014300 04 $882.0014350 03 $714.0015002 42 $452.5915003 42 $452.59

15004 42 $452.5915005 42 $452.5915040 17 $127.7415050 42 $452.5915100 02 $624.4015101 03 $714.0015110 02 $624.4015111 01 $466.2015115 02 $624.4015116 01 $466.2015120 02 $624.4015121 03 $714.0015130 02 $624.4015131 01 $466.2015135 02 $624.4015136 01 $466.2015150 02 $624.4015151 01 $466.2015152 01 $466.2015155 02 $624.4015156 01 $466.2015157 01 $466.2015200 03 $714.0015201 42 $452.5915220 02 $624.4015221 42 $452.5915240 03 $714.0015241 42 $452.5915260 02 $624.4015261 42 $452.5915300 42 $452.5915301 42 $452.5915320 42 $452.5915321 42 $452.5915330 42 $452.5915331 42 $452.5915335 42 $452.5915336 42 $452.5915400 42 $452.5915401 42 $452.59


HCPCS CODE

ASC Payment

Group


HCPCS CODE

ASC Payment

Group


HCPCS CODE

ASC Payment

Group


15420 42 $452.59 15421 42 $452.59 15430 42 $452.59 15431 42 $452.59 15570 03 $714.00 15572 03 $714.00 15574 03 $714.00 15576 03 $714.00 15600 03 $714.00 15610 03 $714.00 15620 04 $882.00 15630 03 $714.00 15650 05 $1,003.80 15731 03 $714.00 15732 03 $714.00 15734 03 $714.00 15736 03 $714.00 15738 03 $714.00 15740 02 $624.40 15750 02 $624.40 15760 02 $624.40 15770 03 $714.00 15775 42 $452.59 15776 42 $452.59 15820 03 $714.00 15821 03 $714.00 15822 03 $714.00 15823 05 $1,003.80 15824 03 $714.00 15825 03 $714.00 15826 03 $714.00 15828 03 $714.00 15829 05 $1,003.80 15830 03 $714.00 15832 03 $714.00 15833 03 $714.00 15834 03 $714.00 15835 42 $452.59 15836 03 $714.00 15839 03 $714.00 15840 04 $882.00 15841 04 $882.00 15845 04 $882.00 15847 03 $714.00

15876 03 $714.0015877 03 $714.0015878 03 $714.0015879 03 $714.0015920 37 $352.1315922 04 $882.0015931 03 $714.0015933 03 $714.0015934 03 $714.0015935 04 $882.0015936 04 $882.0015937 04 $882.0015940 03 $714.0015941 03 $714.0015944 03 $714.0015945 04 $882.0015946 04 $882.0015950 03 $714.0015951 04 $882.0015952 03 $714.0015953 04 $882.0015956 03 $714.0015958 04 $882.0016025 13 $93.9516030 18 $139.7619020 02 $624.4019100 34 $336.0019101 02 $624.4019102 34 $336.0019103 48 $554.0819110 02 $624.4019112 03 $714.0019120 03 $714.0019125 03 $714.0019126 03 $714.0019290 01 $466.2019291 01 $466.2019295 20 $149.4619296 09 $1,874.6019297 09 $1,874.6019298 09 $1,874.6019300 04 $882.0019301 03 $714.0019302 07 $1,393.00

19303 04 $882.0019304 04 $882.0019316 04 $882.0019318 04 $882.0019324 04 $882.0019325 09 $1,874.6019328 01 $466.2019330 01 $466.2019340 02 $624.4019342 03 $714.0019350 04 $882.0019355 04 $882.0019357 05 $1,003.8019366 05 $1,003.8019370 04 $882.0019371 04 $882.0019380 05 $1,003.8020005 02 $624.4020200 02 $624.4020205 03 $714.0020206 34 $336.0020220 37 $352.1320225 51 $585.8920240 02 $624.4020245 03 $714.0020250 03 $714.0020251 03 $714.0020525 03 $714.0020650 03 $714.0020670 01 $466.2020680 03 $714.0020690 02 $624.4020692 03 $714.0020693 03 $714.0020694 01 $466.2020900 03 $714.0020902 04 $882.0020910 03 $714.0020912 03 $714.0020920 04 $882.0020922 03 $714.0020924 04 $882.0020926 04 $882.0020975 10 $52.51

26


HCPCS CODE

ASC Payment

Group


HCPCS CODE

ASC Payment

Group


HCPCS CODE

ASC Payment

Group


21010 02 $624.40 21015 03 $714.00 21025 02 $624.40 21026 02 $624.40 21029 02 $624.40 21034 03 $714.00 21040 02 $624.40 21044 02 $624.40 21046 02 $624.40 21047 02 $624.40 21050 03 $714.00 21060 02 $624.40 21070 03 $714.00 21100 02 $624.40 21120 07 $1,393.00 21121 07 $1,393.00 21122 07 $1,393.00 21123 07 $1,393.00 21125 07 $1,393.00 21127 09 $1,874.60 21181 07 $1,393.00 21206 05 $1,003.80 21208 07 $1,393.00 21209 05 $1,003.80 21210 07 $1,393.00 21215 07 $1,393.00 21230 07 $1,393.00 21235 07 $1,393.00 21240 04 $882.00 21242 05 $1,003.80 21243 05 $1,003.80 21244 07 $1,393.00 21245 07 $1,393.00 21246 07 $1,393.00 21248 07 $1,393.00 21249 07 $1,393.00 21267 07 $1,393.00 21270 05 $1,003.80 21275 07 $1,393.00 21280 05 $1,003.80 21282 05 $1,003.80 21295 01 $466.20 21296 01 $466.20 21310 27 $211.01

21315 27 $211.0121320 02 $624.4021325 04 $882.0021330 05 $1,003.8021335 07 $1,393.0021336 04 $882.0021337 02 $624.4021338 04 $882.0021339 05 $1,003.8021340 04 $882.0021345 07 $1,393.0021355 03 $714.0021356 03 $714.0021400 02 $624.4021401 03 $714.0021421 04 $882.0021445 04 $882.0021450 27 $211.0121451 53 $649.8121452 02 $624.4021453 03 $714.0021454 05 $1,003.8021461 04 $882.0021462 05 $1,003.8021465 04 $882.0021480 27 $211.0121485 02 $624.4021490 03 $714.0021497 02 $624.4021501 02 $624.4021502 02 $624.4021555 02 $624.4021556 02 $624.4021600 02 $624.4021610 02 $624.4021700 02 $624.4021720 03 $714.0021725 16 $123.8421800 19 $145.0721805 02 $624.4021820 19 $145.0721925 02 $624.4021930 02 $624.4021935 03 $714.00

22305 19 $145.0722310 19 $145.0722315 19 $145.0722505 02 $624.4022520 09 $1,874.6022521 09 $1,874.6022522 09 $1,874.6022900 04 $882.0023000 02 $624.4023020 02 $624.4023030 01 $466.2023031 03 $714.0023035 03 $714.0023040 03 $714.0023044 04 $882.0023066 02 $624.4023075 02 $624.4023076 02 $624.4023077 03 $714.0023100 02 $624.4023101 07 $1,393.0023105 04 $882.0023106 04 $882.0023107 04 $882.0023120 05 $1,003.8023125 05 $1,003.8023130 05 $1,003.8023140 04 $882.0023145 05 $1,003.8023146 05 $1,003.8023150 04 $882.0023155 05 $1,003.8023156 05 $1,003.8023170 02 $624.4023172 02 $624.4023174 02 $624.4023180 04 $882.0023182 04 $882.0023184 04 $882.0023190 04 $882.0023195 05 $1,003.8023330 01 $466.2023331 01 $466.2023395 05 $1,003.80

27


HCPCS CODE

HCPCS CODE

HCPCS CODE

ASC Payment

Group

ASC Payment

Group

ASC Payment

Group




23397 07 $1,393.00 23400 07 $1,393.00 23405 02 $624.40 23406 02 $624.40 23410 05 $1,003.80 23412 07 $1,393.00 23415 05 $1,003.80 23420 07 $1,393.00 23430 04 $882.00 23440 04 $882.00 23450 05 $1,003.80 23455 07 $1,393.00 23460 05 $1,003.80 23462 07 $1,393.00 23465 05 $1,003.80 23466 07 $1,393.00 23480 04 $882.00 23485 07 $1,393.00 23490 03 $714.00 23491 03 $714.00 23500 19 $145.07 23505 19 $145.07 23515 03 $714.00 23520 19 $145.07 23525 19 $145.07 23530 03 $714.00 23532 04 $882.00 23540 19 $145.07 23545 19 $145.07 23550 03 $714.00 23552 04 $882.00 23570 19 $145.07 23575 19 $145.07 23585 03 $714.00 23605 19 $145.07 23615 04 $882.00 23616 04 $882.00 23625 19 $145.07 23630 05 $1,003.80 23650 19 $145.07 23655 01 $466.20 23660 03 $714.00 23665 19 $145.07 23670 03 $714.00

23675 19 $145.0723680 03 $714.0023700 01 $466.2023800 04 $882.0023802 07 $1,393.0023921 42 $452.5923930 01 $466.2023931 02 $624.4023935 02 $624.4024000 04 $882.0024006 04 $882.0024066 02 $624.4024075 02 $624.4024076 02 $624.4024077 03 $714.0024100 01 $466.2024101 04 $882.0024102 04 $882.0024105 03 $714.0024110 02 $624.4024115 03 $714.0024116 03 $714.0024120 03 $714.0024125 03 $714.0024126 03 $714.0024130 03 $714.0024134 02 $624.4024136 02 $624.4024138 02 $624.4024140 03 $714.0024145 03 $714.0024147 02 $624.4024155 03 $714.0024160 02 $624.4024164 03 $714.0024201 02 $624.4024301 04 $882.0024305 04 $882.0024310 03 $714.0024320 03 $714.0024330 03 $714.0024331 03 $714.0024340 03 $714.0024341 03 $714.00

24342 03 $714.0024345 02 $624.4024350 03 $714.0024351 03 $714.0024352 03 $714.0024354 03 $714.0024356 03 $714.0024360 05 $1,003.8024361 05 $1,003.8024362 05 $1,003.8024363 07 $1,393.0024365 05 $1,003.8024366 05 $1,003.8024400 04 $882.0024410 04 $882.0024420 03 $714.0024430 03 $714.0024435 04 $882.0024470 03 $714.0024495 02 $624.4024498 03 $714.0024500 19 $145.0724505 19 $145.0724515 04 $882.0024516 04 $882.0024530 19 $145.0724535 19 $145.0724538 02 $624.4024545 04 $882.0024546 05 $1,003.8024560 19 $145.0724565 19 $145.0724566 02 $624.4024575 03 $714.0024576 19 $145.0724577 19 $145.0724579 03 $714.0024582 02 $624.4024586 04 $882.0024587 05 $1,003.8024600 19 $145.0724605 02 $624.4024615 03 $714.0024620 19 $145.07

28


HCPCS CODE

HCPCS CODE

HCPCS CODE

25565

ASC Payment

Group

ASC Payment

Group

ASC Payment

Group

19




$145.07

24635 03 $714.00 24655 19 $145.07 24665 04 $882.00 24666 04 $882.00 24670 19 $145.07 24675 19 $145.07 24685 03 $714.00 24800 04 $882.00 24802 05 $1,003.80 24925 03 $714.00 25000 03 $714.00 25020 03 $714.00 25023 03 $714.00 25024 03 $714.00 25025 03 $714.00 25028 01 $466.20 25031 02 $624.40 25035 02 $624.40 25040 05 $1,003.80 25066 02 $624.40 25075 02 $624.40 25076 03 $714.00 25077 03 $714.00 25085 03 $714.00 25100 02 $624.40 25101 03 $714.00 25105 04 $882.00 25107 03 $714.00 25110 03 $714.00 25111 03 $714.00 25112 04 $882.00 25115 04 $882.00 25116 04 $882.00 25118 02 $624.40 25119 03 $714.00 25120 03 $714.00 25125 03 $714.00 25126 03 $714.00 25130 03 $714.00 25135 03 $714.00 25136 03 $714.00 25145 02 $624.40 25150 02 $624.40 25151 02 $624.40

25210 03 $714.0025215 04 $882.0025230 04 $882.0025240 04 $882.0025248 02 $624.4025250 01 $466.2025251 01 $466.2025260 04 $882.0025263 02 $624.4025265 03 $714.0025270 04 $882.0025272 03 $714.0025274 04 $882.0025275 04 $882.0025280 04 $882.0025290 03 $714.0025295 03 $714.0025300 03 $714.0025301 03 $714.0025310 03 $714.0025312 04 $882.0025315 03 $714.0025316 03 $714.0025320 03 $714.0025332 05 $1,003.8025335 03 $714.0025337 05 $1,003.8025350 03 $714.0025355 03 $714.0025360 03 $714.0025365 03 $714.0025370 03 $714.0025375 04 $882.0025390 03 $714.0025391 04 $882.0025392 03 $714.0025393 04 $882.0025400 03 $714.0025405 04 $882.0025415 03 $714.0025420 04 $882.0025425 03 $714.0025426 04 $882.0025440 04 $882.00

25441 05 $1,003.8025442 05 $1,003.8025443 05 $1,003.8025444 05 $1,003.8025445 05 $1,003.8025446 07 $1,393.0025447 05 $1,003.8025449 05 $1,003.8025450 03 $714.0025455 03 $714.0025490 03 $714.0025491 03 $714.0025492 03 $714.0025505 19 $145.0725515 03 $714.0025520 19 $145.0725525 04 $882.0025526 05 $1,003.8025535 19 $145.0725545 03 $714.00

25574 03 $714.0025575 03 $714.0025605 19 $145.0725606 03 $714.0025607 05 $1,003.8025608 05 $1,003.8025609 05 $1,003.8025624 19 $145.0725628 03 $714.0025635 19 $145.0725645 03 $714.0025660 19 $145.0725670 03 $714.0025671 01 $466.2025675 19 $145.0725676 02 $624.4025680 19 $145.0725685 03 $714.0025690 19 $145.0725695 02 $624.4025800 04 $882.0025805 05 $1,003.8025810 05 $1,003.80

29


HCPCS CODE

HCPCS CODE

HCPCS CODE

ASC Payment

Group

ASC Payment

Group

ASC Payment

Group




25820 04 $882.00 25825 05 $1,003.80 25830 05 $1,003.80 25907 03 $714.00 25922 03 $714.00 25929 03 $714.00 26011 01 $466.20 26020 02 $624.40 26025 01 $466.20 26030 02 $624.40 26034 02 $624.40 26040 04 $882.00 26045 03 $714.00 26055 02 $624.40 26060 02 $624.40 26070 02 $624.40 26075 04 $882.00 26080 04 $882.00 26100 02 $624.40 26105 01 $466.20 26110 01 $466.20 26115 02 $624.40 26116 02 $624.40 26117 03 $714.00 26121 04 $882.00 26123 04 $882.00 26125 04 $882.00 26130 03 $714.00 26135 04 $882.00 26140 02 $624.40 26145 03 $714.00 26160 03 $714.00 26170 03 $714.00 26180 03 $714.00 26185 04 $882.00 26200 02 $624.40 26205 03 $714.00 26210 02 $624.40 26215 03 $714.00 26230 54 $1,390.13 26235 03 $714.00 26236 03 $714.00 26250 03 $714.00 26255 03 $714.00

26260 03 $714.0026261 03 $714.0026262 02 $624.4026320 02 $624.4026350 01 $466.2026352 04 $882.0026356 04 $882.0026357 04 $882.0026358 04 $882.0026370 04 $882.0026372 04 $882.0026373 03 $714.0026390 04 $882.0026392 03 $714.0026410 03 $714.0026412 03 $714.0026415 04 $882.0026416 03 $714.0026418 04 $882.0026420 04 $882.0026426 03 $714.0026428 03 $714.0026432 03 $714.0026433 03 $714.0026434 03 $714.0026437 03 $714.0026440 03 $714.0026442 03 $714.0026445 03 $714.0026449 03 $714.0026450 03 $714.0026455 03 $714.0026460 03 $714.0026471 02 $624.4026474 02 $624.4026476 01 $466.2026477 01 $466.2026478 01 $466.2026479 01 $466.2026480 03 $714.0026483 03 $714.0026485 02 $624.4026489 03 $714.0026490 03 $714.00

26492 03 $714.0026494 03 $714.0026496 03 $714.0026497 03 $714.0026498 04 $882.0026499 03 $714.0026500 04 $882.0026502 04 $882.0026508 03 $714.0026510 03 $714.0026516 01 $466.2026517 03 $714.0026518 03 $714.0026520 03 $714.0026525 03 $714.0026530 03 $714.0026531 07 $1,393.0026535 05 $1,003.8026536 05 $1,003.8026540 04 $882.0026541 07 $1,393.0026542 04 $882.0026545 04 $882.0026546 04 $882.0026548 04 $882.0026550 02 $624.4026555 03 $714.0026560 02 $624.4026561 03 $714.0026562 04 $882.0026565 05 $1,003.8026567 05 $1,003.8026568 03 $714.0026580 05 $1,003.8026587 05 $1,003.8026590 05 $1,003.8026591 03 $714.0026593 03 $714.0026596 02 $624.4026605 19 $145.0726607 19 $145.0726608 04 $882.0026615 04 $882.0026645 19 $145.07

30


HCPCS CODE

HCPCS CODE

HCPCS CODE

ASC Payment

Group

ASC Payment

Group

ASC Payment

Group




26650 02 $624.40 26665 04 $882.00 26675 19 $145.07 26676 02 $624.40 26685 03 $714.00 26686 03 $714.00 26705 19 $145.07 26706 19 $145.07 26715 04 $882.00 26727 07 $1,393.00 26735 04 $882.00 26742 19 $145.07 26746 05 $1,003.80 26756 02 $624.40 26765 04 $882.00 26776 02 $624.40 26785 02 $624.40 26820 05 $1,003.80 26841 04 $882.00 26842 04 $882.00 26843 03 $714.00 26844 03 $714.00 26850 04 $882.00 26852 04 $882.00 26860 03 $714.00 26861 02 $624.40 26862 04 $882.00 26863 03 $714.00 26910 03 $714.00 26951 02 $624.40 26952 04 $882.00 26990 01 $466.20 26991 01 $466.20 27000 02 $624.40 27001 03 $714.00 27003 03 $714.00 27033 03 $714.00 27035 04 $882.00 27040 01 $466.20 27041 51 $585.89 27047 02 $624.40 27048 03 $714.00 27049 03 $714.00 27050 03 $714.00

27052 03 $714.0027060 05 $1,003.8027062 05 $1,003.8027065 05 $1,003.8027066 05 $1,003.8027067 05 $1,003.8027080 02 $624.4027086 01 $466.2027087 03 $714.0027097 03 $714.0027098 03 $714.0027100 04 $882.0027105 04 $882.0027110 04 $882.0027111 04 $882.0027193 19 $145.0727194 02 $624.4027202 02 $624.4027230 19 $145.0727238 19 $145.0727246 19 $145.0727250 19 $145.0727252 02 $624.4027257 03 $714.0027265 19 $145.0727266 02 $624.4027275 02 $624.4027301 03 $714.0027305 02 $624.4027306 03 $714.0027307 03 $714.0027310 04 $882.0027323 01 $466.2027324 01 $466.2027325 02 $624.4027326 02 $624.4027327 02 $624.4027328 03 $714.0027329 04 $882.0027330 04 $882.0027331 04 $882.0027332 04 $882.0027333 04 $882.0027334 04 $882.00

27335 04 $882.0027340 03 $714.0027345 04 $882.0027347 04 $882.0027350 04 $882.0027355 03 $714.0027356 04 $882.0027357 05 $1,003.8027358 05 $1,003.8027360 05 $1,003.8027372 07 $1,393.0027380 01 $466.2027381 03 $714.0027385 03 $714.0027386 03 $714.0027390 01 $466.2027391 02 $624.4027392 03 $714.0027393 02 $624.4027394 03 $714.0027395 03 $714.0027396 03 $714.0027397 03 $714.0027400 03 $714.0027403 04 $882.0027405 04 $882.0027407 04 $882.0027409 04 $882.0027418 03 $714.0027420 03 $714.0027422 07 $1,393.0027424 03 $714.0027425 07 $1,393.0027427 03 $714.0027428 04 $882.0027429 04 $882.0027430 04 $882.0027435 04 $882.0027437 04 $882.0027438 05 $1,003.8027441 05 $1,003.8027442 05 $1,003.8027443 05 $1,003.8027496 05 $1,003.80

31


HCPCS CODE

HCPCS CODE

HCPCS CODE

ASC Payment

Group

ASC Payment

Group

ASC Payment

Group




27497 03 $714.00 27498 03 $714.00 27499 03 $714.00 27500 19 $145.07 27501 19 $145.07 27502 19 $145.07 27503 19 $145.07 27508 19 $145.07 27509 03 $714.00 27510 19 $145.07 27516 19 $145.07 27517 19 $145.07 27520 19 $145.07 27530 19 $145.07 27532 19 $145.07 27538 19 $145.07 27550 19 $145.07 27552 01 $466.20 27560 19 $145.07 27562 01 $466.20 27566 02 $624.40 27570 01 $466.20 27594 03 $714.00 27600 03 $714.00 27601 03 $714.00 27602 03 $714.00 27603 02 $624.40 27604 02 $624.40 27605 01 $466.20 27606 01 $466.20 27607 02 $624.40 27610 02 $624.40 27612 03 $714.00 27614 02 $624.40 27615 03 $714.00 27618 02 $624.40 27619 03 $714.00 27620 04 $882.00 27625 04 $882.00 27626 04 $882.00 27630 03 $714.00 27635 03 $714.00 27637 03 $714.00 27638 03 $714.00

27640 02 $624.4027641 02 $624.4027647 03 $714.0027650 03 $714.0027652 03 $714.0027654 03 $714.0027656 02 $624.4027658 01 $466.2027659 02 $624.4027664 02 $624.4027665 02 $624.4027675 02 $624.4027676 03 $714.0027680 03 $714.0027681 02 $624.4027685 03 $714.0027686 03 $714.0027687 03 $714.0027690 04 $882.0027691 04 $882.0027692 03 $714.0027695 02 $624.4027696 02 $624.4027698 02 $624.4027700 05 $1,003.8027704 02 $624.4027705 02 $624.4027707 02 $624.4027709 02 $624.4027730 02 $624.4027732 02 $624.4027734 02 $624.4027740 02 $624.4027742 02 $624.4027745 03 $714.0027750 19 $145.0727752 19 $145.0727756 03 $714.0027758 04 $882.0027759 04 $882.0027760 19 $145.0727762 19 $145.0727766 03 $714.0027780 19 $145.07

27781 19 $145.0727784 03 $714.0027786 19 $145.0727788 19 $145.0727792 03 $714.0027808 19 $145.0727810 19 $145.0727814 03 $714.0027816 19 $145.0727818 19 $145.0727822 03 $714.0027823 03 $714.0027824 19 $145.0727825 19 $145.0727826 03 $714.0027827 03 $714.0027828 04 $882.0027829 02 $624.4027830 19 $145.0727831 19 $145.0727832 02 $624.4027840 19 $145.0727842 01 $466.2027846 03 $714.0027848 03 $714.0027860 01 $466.2027870 04 $882.0027871 04 $882.0027884 03 $714.0027889 03 $714.0027892 03 $714.0027893 03 $714.0027894 03 $714.0028002 03 $714.0028003 03 $714.0028005 03 $714.0028008 03 $714.0028011 03 $714.0028020 02 $624.4028022 02 $624.4028024 02 $624.4028035 04 $882.0028043 02 $624.4028045 03 $714.00

32


HCPCS CODE

HCPCS CODE

HCPCS CODE

ASC Payment

Group

ASC Payment

Group

ASC Payment

Group




28046 03 $714.00 28050 02 $624.40 28052 02 $624.40 28054 02 $624.40 28055 04 $882.00 28060 02 $624.40 28062 03 $714.00 28070 03 $714.00 28072 03 $714.00 28080 03 $714.00 28086 02 $624.40 28088 02 $624.40 28090 03 $714.00 28092 03 $714.00 28100 02 $624.40 28102 03 $714.00 28103 03 $714.00 28104 02 $624.40 28106 03 $714.00 28107 03 $714.00 28108 02 $624.40 28110 03 $714.00 28111 03 $714.00 28112 03 $714.00 28113 03 $714.00 28114 03 $714.00 28116 03 $714.00 28118 04 $882.00 28119 04 $882.00 28120 07 $1,393.00 28122 03 $714.00 28126 03 $714.00 28130 03 $714.00 28140 03 $714.00 28150 03 $714.00 28153 03 $714.00 28160 03 $714.00 28171 03 $714.00 28173 03 $714.00 28175 03 $714.00 28192 02 $624.40 28193 51 $585.89 28200 03 $714.00 28202 03 $714.00

28208 03 $714.0028210 03 $714.0028222 01 $466.2028225 01 $466.2028226 01 $466.2028234 02 $624.4028238 03 $714.0028240 02 $624.4028250 03 $714.0028260 03 $714.0028261 03 $714.0028262 04 $882.0028264 01 $466.2028270 03 $714.0028280 02 $624.4028285 03 $714.0028286 04 $882.0028288 03 $714.0028289 03 $714.0028290 02 $624.4028292 02 $624.4028293 03 $714.0028294 03 $714.0028296 03 $714.0028297 03 $714.0028298 03 $714.0028299 05 $1,003.8028300 02 $624.4028302 02 $624.4028304 02 $624.4028305 03 $714.0028306 04 $882.0028307 04 $882.0028308 02 $624.4028309 04 $882.0028310 03 $714.0028312 03 $714.0028313 02 $624.4028315 04 $882.0028320 04 $882.0028322 04 $882.0028340 04 $882.0028341 04 $882.0028344 04 $882.00

28345 04 $882.0028400 19 $145.0728405 19 $145.0728406 02 $624.4028415 03 $714.0028420 04 $882.0028435 19 $145.0728436 02 $624.4028445 03 $714.0028456 02 $624.4028465 03 $714.0028476 02 $624.4028485 04 $882.0028496 02 $624.4028505 03 $714.0028525 03 $714.0028531 03 $714.0028545 01 $466.2028546 02 $624.4028555 02 $624.4028575 19 $145.0728576 03 $714.0028585 03 $714.0028605 19 $145.0728606 02 $624.4028615 03 $714.0028635 01 $466.2028636 03 $714.0028645 03 $714.0028665 01 $466.2028666 03 $714.0028675 03 $714.0028705 04 $882.0028715 04 $882.0028725 04 $882.0028730 04 $882.0028735 04 $882.0028737 05 $1,003.8028740 04 $882.0028750 04 $882.0028755 04 $882.0028760 04 $882.0028810 02 $624.4028820 02 $624.40

33


HCPCS CODE

HCPCS CODE

30160

HCPCS CODE

ASC Payment

Group

ASC Payment

Group

04

ASC Payment

Group



$882.00


28825 02 $624.40 29800 03 $714.00 29804 03 $714.00 29805 03 $714.00 29806 03 $714.00 29807 03 $714.00 29819 03 $714.00 29820 03 $714.00 29821 03 $714.00 29822 03 $714.00 29823 03 $714.00 29824 05 $1,003.80 29825 03 $714.00 29826 03 $714.00 29827 05 $1,003.80 29830 03 $714.00 29834 03 $714.00 29835 03 $714.00 29836 03 $714.00 29837 03 $714.00 29838 03 $714.00 29840 03 $714.00 29843 03 $714.00 29844 03 $714.00 29845 03 $714.00 29846 03 $714.00 29847 03 $714.00 29848 09 $1,874.60 29850 04 $882.00 29851 04 $882.00 29855 04 $882.00 29856 04 $882.00 29860 04 $882.00 29861 04 $882.00 29862 09 $1,874.60 29863 04 $882.00 29870 03 $714.00 29871 03 $714.00 29873 03 $714.00 29874 03 $714.00 29875 04 $882.00 29876 04 $882.00 29877 04 $882.00 29879 03 $714.00

29880 04 $882.0029881 04 $882.0029882 03 $714.0029883 03 $714.0029884 03 $714.0029885 03 $714.0029886 03 $714.0029887 03 $714.0029888 03 $714.0029889 03 $714.0029891 03 $714.0029892 03 $714.0029893 55 $1,757.7829894 03 $714.0029895 03 $714.0029897 03 $714.0029898 03 $714.0029899 03 $714.0029900 03 $714.0029901 03 $714.0029902 03 $714.0030115 02 $624.4030117 03 $714.0030118 03 $714.0030120 01 $466.2030125 02 $624.4030130 03 $714.0030140 02 $624.4030150 03 $714.00

30220 53 $649.8130310 01 $466.2030320 02 $624.4030400 04 $882.0030410 05 $1,003.8030420 05 $1,003.8030430 03 $714.0030435 05 $1,003.8030450 07 $1,393.0030460 07 $1,393.0030462 09 $1,874.6030465 09 $1,874.6030520 04 $882.0030540 05 $1,003.80

30545 05 $1,003.8030560 27 $211.0130580 04 $882.0030600 04 $882.0030620 07 $1,393.0030630 07 $1,393.0030801 01 $466.2030802 01 $466.2030903 14 $101.4730905 14 $101.4730906 14 $101.4730915 02 $624.4030920 03 $714.0030930 04 $882.0031020 02 $624.4031030 03 $714.0031032 04 $882.0031050 02 $624.4031051 04 $882.0031070 02 $624.4031075 04 $882.0031080 04 $882.0031081 04 $882.0031084 04 $882.0031085 04 $882.0031086 04 $882.0031087 04 $882.0031090 05 $1,003.8031200 02 $624.4031201 05 $1,003.8031205 03 $714.0031233 15 $120.9531235 01 $466.2031237 02 $624.4031238 01 $466.2031239 04 $882.0031240 02 $624.4031254 03 $714.0031255 05 $1,003.8031256 03 $714.0031267 03 $714.0031276 03 $714.0031287 03 $714.0031288 03 $714.00

34


HCPCS CODE

HCPCS CODE

HCPCS CODE

ASC Payment

Group

ASC Payment

Group

ASC Payment

Group




31300 05 $1,003.80 31320 02 $624.40 31400 02 $624.40 31420 02 $624.40 31510 02 $624.40 31511 15 $120.95 31512 02 $624.40 31513 15 $120.95 31515 01 $466.20 31525 01 $466.20 31526 02 $624.40 31527 01 $466.20 31528 02 $624.40 31529 02 $624.40 31530 02 $624.40 31531 03 $714.00 31535 02 $624.40 31536 03 $714.00 31540 03 $714.00 31541 04 $882.00 31545 04 $882.00 31546 04 $882.00 31560 05 $1,003.80 31561 05 $1,003.80 31570 02 $624.40 31571 02 $624.40 31576 02 $624.40 31577 33 $330.99 31578 02 $624.40 31580 05 $1,003.80 31582 05 $1,003.80 31588 05 $1,003.80 31590 05 $1,003.80 31595 02 $624.40 31603 01 $466.20 31611 03 $714.00 31612 01 $466.20 31613 02 $624.40 31614 02 $624.40 31615 01 $466.20 31620 01 $466.20 31622 01 $466.20 31623 02 $624.40 31624 02 $624.40

31625 02 $624.4031628 02 $624.4031629 02 $624.4031630 02 $624.4031631 02 $624.4031635 02 $624.4031636 02 $624.4031637 01 $466.2031638 02 $624.4031640 02 $624.4031641 02 $624.4031643 02 $624.4031645 01 $466.2031646 01 $466.2031656 01 $466.2031717 33 $330.9931720 11 $66.2531730 33 $330.9931750 05 $1,003.8031755 02 $624.4031820 01 $466.2031825 02 $624.4031830 02 $624.4032000 32 $311.8932400 01 $466.2032405 01 $466.2032420 32 $311.8933010 32 $311.8933011 32 $311.8933212 03 $714.0033213 03 $714.0033222 02 $624.4033223 02 $624.4033233 02 $624.4035188 04 $882.0035207 04 $882.0035875 09 $1,874.6035876 09 $1,874.6036260 03 $714.0036261 02 $624.4036262 01 $466.2036475 09 $1,874.6036476 09 $1,874.6036478 09 $1,874.60

36479 09 $1,874.6036555 01 $466.2036556 01 $466.2036557 02 $624.4036558 02 $624.4036560 03 $714.0036561 03 $714.0036563 03 $714.0036565 03 $714.0036566 03 $714.0036568 01 $466.2036569 01 $466.2036570 03 $714.0036571 03 $714.0036575 02 $624.4036576 02 $624.4036578 02 $624.4036580 01 $466.2036581 02 $624.4036582 03 $714.0036583 03 $714.0036584 01 $466.2036585 03 $714.0036589 01 $466.2036590 01 $466.2036640 01 $466.2036800 03 $714.0036810 03 $714.0036815 03 $714.0036818 03 $714.0036819 03 $714.0036820 03 $714.0036821 03 $714.0036825 04 $882.0036830 04 $882.0036831 09 $1,874.6036832 04 $882.0036833 04 $882.0036834 03 $714.0036835 04 $882.0036860 22 $178.3636861 03 $714.0036870 09 $1,874.6037500 03 $714.00

35


HCPCS CODE

HCPCS CODE

HCPCS CODE

ASC Payment

Group

ASC Payment

Group

ASC Payment

Group




37607 03 $714.00 37609 02 $624.40 37650 02 $624.40 37700 02 $624.40 37718 03 $714.00 37722 03 $714.00 37735 03 $714.00 37760 03 $714.00 37780 03 $714.00 37785 03 $714.00 37790 03 $714.00 38300 01 $466.20 38305 02 $624.40 38308 02 $624.40 38500 02 $624.40 38505 34 $336.00 38510 02 $624.40 38520 02 $624.40 38525 02 $624.40 38530 02 $624.40 38542 02 $624.40 38550 03 $714.00 38555 04 $882.00 38570 09 $1,874.60 38571 09 $1,874.60 38572 09 $1,874.60 38740 02 $624.40 38745 04 $882.00 38760 02 $624.40 40500 02 $624.40 40510 02 $624.40 40520 02 $624.40 40525 02 $624.40 40527 02 $624.40 40530 02 $624.40 40650 53 $649.81 40652 53 $649.81 40654 53 $649.81 40700 07 $1,393.00 40701 07 $1,393.00 40720 07 $1,393.00 40761 03 $714.00 40801 02 $624.40 40814 02 $624.40

40816 02 $624.4040818 27 $211.0140819 01 $466.2040831 01 $466.2040840 02 $624.4040842 03 $714.0040843 03 $714.0040844 05 $1,003.8040845 05 $1,003.8041005 27 $211.0141006 01 $466.2041007 01 $466.2041008 01 $466.2041009 27 $211.0141010 01 $466.2041015 27 $211.0141016 01 $466.2041017 01 $466.2041018 01 $466.2041112 02 $624.4041113 02 $624.4041114 02 $624.4041116 01 $466.2041120 05 $1,003.8041250 27 $211.0141251 27 $211.0141252 02 $624.4041500 01 $466.2041510 01 $466.2041520 02 $624.4041800 16 $123.8441827 02 $624.4042000 27 $211.0142107 02 $624.4042120 04 $882.0042140 02 $624.4042145 05 $1,003.8042180 27 $211.0142182 02 $624.4042200 05 $1,003.8042205 05 $1,003.8042210 05 $1,003.8042215 07 $1,393.0042220 05 $1,003.80

42226 05 $1,003.8042235 05 $1,003.8042260 04 $882.0042300 01 $466.2042305 02 $624.4042310 27 $211.0142320 27 $211.0142340 02 $624.4042405 02 $624.4042408 03 $714.0042409 03 $714.0042410 03 $714.0042415 07 $1,393.0042420 07 $1,393.0042425 07 $1,393.0042440 03 $714.0042450 02 $624.4042500 03 $714.0042505 04 $882.0042507 03 $714.0042508 04 $882.0042509 04 $882.0042510 04 $882.0042600 01 $466.2042665 07 $1,393.0042700 27 $211.0142720 01 $466.2042725 02 $624.4042802 01 $466.2042804 01 $466.2042806 02 $624.4042808 02 $624.4042810 03 $714.0042815 05 $1,003.8042820 03 $714.0042821 05 $1,003.8042825 04 $882.0042826 04 $882.0042830 04 $882.0042831 04 $882.0042835 04 $882.0042836 04 $882.0042860 03 $714.0042870 03 $714.00

36


HCPCS CODE

HCPCS CODE

HCPCS CODE

ASC Payment

Group

ASC Payment

Group

ASC Payment

Group



hospital and ambulatory surgery center payment manual 2006 · 2017. 1. 5. · on june 26, 2006 the...

Documents